What happens when you put a couple of dozen doctors, technology vendors, consumer advocates, researchers, public health officials, state legislators and others in a room and ask them to agree on exactly what it means to ‘meaningfully use’ electronic health records? Not as many fights as you’d think. And thanks to the Federal Advisory Committees Act [1] – which created the FACAs responsible for creating the first draft of Meaningful Use criteria – we know!
For those of you who don’t live and breathe health information technology (health IT) policy every day, here’s the skinny…
From congressional committee testimony to guest editorials and blog posts, we hear voices blasting the (supposed) shortcomings of the Electronic Health Record (EHR) ‘Meaningful Use’ Incentive Program: There’s not enough flexibility! What about interoperability? We need a more thoughtful approach! Why aren’t we focusing on outcomes?
Sometimes I wonder if people think Meaningful Use objectives are randomly picked out of a hat, with measures drafted in Klingon and then back-translated to English, and thresholds determined by throwing darts at a scoreboard . . . blindfolded. In other words, as a slapdash, uneducated guessing game, rather than the deliberate, transparent, informed, rather painstaking process it is, guided by experts in health, care delivery, technology, privacy, and patient engagement.
Years before a particular stage of Meaningful Use – and there are at least three – is scheduled to begin, the HIT Policy Committee (HITPC) begins to contemplate potential policy requirements, while the HIT Standards Committee (HITSC) examines the technological capabilities of EHRs. Workgroups are formed, as well as subgroups of those workgroups, to tackle individual policy priorities. Even the (awesomely-named) “Tiger” and “Power” teams are established. These groups spend months deliberating – evaluating past experience, current performance, and future trends – before crafting recommendations to bring back to the full HITPC or HITSC. The entire process is supported by the dogged (and dog-tired) staff at the Office of the National Coordinator for Health IT (ONC, the younger federal sibling of the Centers for Medicare & Medicaid Services (CMS), which is responsible for coordinating the nationwide adoption of health IT).
In this phase, the Meaningful Use policy requirements are endlessly tweaked and recalibrated, like fine-tuning Yo-Yo Ma’s cello. Members discuss whether to include proposed objectives as either core (required) or menu (optional) or “certification only” criteria, meaning the function is built into the EHR but it isn’t required to be used (yet). Some objectives are considered for the next stage (currently Stage 3) or punted to “future stages.” Measure thresholds are adjusted up or down depending upon lessons learned or the realities in the field – and often readjusted based upon public feedback. HITPC members pay as much attention to language and word choice as Shakespearean scholars; 15-minute discussions over a single word in an objective or measure are typical.
As the Meaningful Use objectives take shape, there are multiple opportunities for nationwide public debate and input: workgroup and full committee discussions are open to the public, hearings are held, and formal comment periods are offered by full committees in the form of a Request for Public Comment. Discussion and refinement continues as FACA members consider public feedback and proposed requirements move back and forth between the workgroup and full committee levels. Ultimately, both the HITPC and HITSC submit recommendations to federal officials, and ONC and CMS publish proposed and final regulations on both the policy and technical certification requirements, again with opportunities for public comment. Vendors finish building the EHR systems and get to work implementing them, providers prepare to adjust their workflows accordingly, patients and families experience the benefits, and the FACAs forge ahead to the next stage.
And you can follow along every step of the way! Each full committee, workgroup, subgroup, Power and Tiger Team meeting is open to the public, with time set aside for public comment, and there is always a public rulemaking process where anyone can weigh in. If you have that kind of time on your hands, of course. By my rough calculations, FACA committee members and relevant ONC staff have spent close to 400 hours in 2013 alone deliberating health IT policy.
You know all of those other cool reforms we’re trying to implement in health care – Accountable Care Organizations (ACOs), patient centered medical homes, and pretty much every CMS Innovation Center initiative? Many of our best ideas to improve the way we pay for and deliver care hinge on the availability and seamless exchange of health information. In other words, these models all depend on the policy and technological foundation these folks are building.
The evolving set of requirements that constitutes “meaningful use” of EHRs is not the result of blunt, broad strokes; the requirements are selected and revised following months and years of gathering evidence, heated discussion, modification, more discussion, and additional refinement.
OK, perhaps determining the requirements for Meaningful Use is a bit mystifying from time to time. The members of the HIT Policy and Standards committees, and ONC and CMS staff, have taken on an unprecedented challenge in transforming the health care system; they are not soothsayers who can read the future, and a few missteps are inevitable. However, there is no doubt that these dedicated professionals respect the magnitude and import of their challenge, and are uniquely aware of the importance of getting it right.
Let’s give them, and the process, the appreciation it deserves. After all, there is a crucial difference between a guess and a highly informed, evidence-based, educated guess. As psychologist Jerome Bruner once said:
“The shrewd guess, the fertile hypothesis, the courageous leap to a tentative conclusion – these are the most valuable coin of the thinker at work.”
